INSTRUCTION TO COMPLETE COMPLAINT FORM

Copy and Paste the “TITLE VI/ CIVIL RIGHTS COMPLAINT FORM” into a word-processing program. Mail the completed form to Benny Bergantino, Title VI Manager, Division of Statewide Planning, One Capitol Hill, Providence, RI 02908. For additional questions or concerns, email Benny Bergantino or call (401) 222-1755.

 


TITLE VI/ CIVIL RIGHTS COMPLAINT FORM

Contact Information
Name
Address
City
State
Zip
Home Phone
Work Phone
Email

Discrimination Complaint

Name of Staff Person that You Believe Discriminated Against You
Date of Alleged Incident

You were discriminated against because of:

Title VI
1 Color
2 National Origin
3 Race

Other Statutes
1 Age
2 Disability
3 Sex

Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also attach any written material pertaining to your case such as any persons (witnesses, fellow employees, supervisors, or others), if known, whom we may contact for additional information to support or clarify your complaint. (Please be sure to provide contact information, and use additional sheets if necessary.)

 

Signature
Date